Just in time for World Breastfeeding Week, which kicked off August 1, the World Health Organization, along with UNICEF issued a report urging women to begin breastfeeding an infant within moments of birth in order to avoid an increased risk of death of the baby.
While well-meaning, that simplistic message ignores the many complications that can come with delivery, such as problematic births or C-section deliveries, as well as the newborn’s health status. For example, babies born via C-section often experience a delayed transition with rapid breathing. Giving them oxygen and respiratory support is more important than feeding them and putting them at risk of aspiration. The mother might also be experiencing her own difficulties like being too sedated from anesthesia or managing the condition that warranted the surgery in the first place.
Sadly, these one-size-fits-all policies on breastfeeding have become the norm. Last month, the Trump Administration attempted to soften the language in a UN-created global breastfeeding pledge, which encouraged nations – including developing nations – to “promote, protect and support” breastfeeding, exclusively, over alternative nutrition sources like formula.
The New York Times headline on the U.S. position then was predictably overwrought: “Opposition to Breast-Feeding Resolution by U.S. Stuns World Health Officials.” Immediate assumptions of nefarious intent spread like wildfire and the Trump Administration was portrayed as betraying our nation and the world.
Yet, as a medical doctor, I am stunned that none of the unintended adverse consequences of “at all costs breastfeeding” campaigns have been mentioned in this ongoing public health narrative. Nor has the fact that, to date, not one country in the world has met the “breastfeeding standards” set forth by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF).
Perhaps it’s therefore worthwhile that the US delegation questioned the pledge’s value and asked, are these goals even attainable? More importantly, should they be?
First, let’s examine why the World Health Assembly’s resolution needs revision. On July 9, President Trump tweeted “The U.S. strongly supports breast feeding but we don’t believe women should be denied access to formula. Many women need this option because of malnutrition and poverty.” He is right. What nursing mom ingests, baby ingests. If she is malnourished, baby is malnourished. Every woman, no matter where in the world, should know all her options (and be able to access them) to best nurture her baby. You can be a champion of breastfeeding and appreciate this reality at the same time.
In developing nations and in areas that have experienced a natural disaster, water sanitation is or can become a major problem. Since ready-made formulas (those that come ready to drink) are more expensive and not as easily accessible, many parents in the U.S. and developing nations choose to buy powdered formulas that need to be reconstituted with water, which in some countries or due to disasters, can become contaminated. As such, the World Health Assembly wants governments to push women to breastfeed, because breast milk is ready-made.
Yet, the resolution doesn’t account for the fact that in some developing nations, women cannot breastfeed, either because they’re simply unable for biological reasons (like many women in Western nations) or because the mother’s nutrition is also compromised—because of the very thing the UN is worried about, poor sanitation, contaminated water, and lack of refrigeration. Under these circumstances, a child could be harmed if their mother was urged or forced to breastfeed (or do so exclusively).
What might be better is to direct attention, and international aid, to water purification systems, infection control measures, and implementing lasting public health infrastructures, along with improved vaccination campaigns, which would solve many of these issues and likely make a greater dent in disease burdens and yield greater dividends.
Additionally, this pledge applies to all nations, even those with reliably clean water and good sanitation systems. In many Western nations, women are routinely criticized for failing to breastfeed. The stigma and guilt is so bad that the London-based Royal College of Midwives (RCM) released a new position statement that “the decision of whether or not to breastfeed is a woman’s choice and must be respected.”
While breastfeeding is indeed a good choice, “breast only” policies often reflect an ideology about how babies should be fed, not clinical status and medical realities. For example, The Global Breastfeeding Collective (a WHO-UNICEF conglomerate) leaves no room for nuanced thinking, maintaining its superiority “in almost all difficult situations” especially “exceptionally difficult circumstances.”
How do such demands impact the mother with breast cancer on chemotherapy that is toxic to her nursing infant? Should the women with postpartum depression feel guilty for bottle-feeding? What about a woman who is in intensive care from an urgent surgical delivery? Compounding the pressure during catastrophic or stressful scenarios helps no one—least of all, the child.
No one disputes that breast milk has many protective benefits. But, it is one of many factors that contribute to the overall development of a healthy child. Formula also can and has saved lives. When breast milk is calorie-insufficient because a mother is malnourished or there is inadequate supply, the baby can fail to thrive. In these and other instances, the existence of this alternative is an invaluable option.
Governments would do better to stress the need for clean water and how to recognize signs of infant starvation or dehydration, rather than telling moms to pass on a vital supplement like baby formula and urging every mom—even those who have had difficult deliveries—to begin breastfeeding immediately after birth. Casting wide nets in infant feeding policies when the countries of comparison are so vastly different ignores the unique challenges and barriers between disparate nations.